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APPLICATION FOR TUITION REIMBURSEMENT PROGRAM
Employee Name	Job Title			Date of Hire
School Name	Soc. Sec. No.
Have you been a permanent full-time active employee for at least one Semester? Yes No

IF THERE IS A QUESTION CONCERNING THIS APPLICATION I MAY BE REACHED AT:
Work Number		Home Telephone
Grade/Subject Assignment:		Home Address
JSU Advisor		School Phone
REQUEST FOR COURSE APPROVAL
Academic Term Applying: Fall Spring Summer
Course Date	Course End Date	Job Related: Yes No	Is course part of a planned degree program? Yes No
Degree Sought		Classification	Anticipated Date of Graduation:
Major		Reason for taking the course
Course Code		Course Title
Tuition	Do you expect to receive GI Benefits, a Grant or Scholarship?			If Yes, amount of aid:

I understand that I must have a grade of “B” or better for all graduate courses or a grade of “C” or better for all undergraduate courses in order to be eligible for reimbursement up to $3,600 in tuition costs each fiscal year. I understand that I must submit an official copy of my grades and a statement from the school stating how much I paid for the course (s) taken prior to the end of the fiscal year to be reimbursed. I understand that if I voluntarily terminate employment in an MLA School, I will be required to reimburse MLI for all education assistance paid to me within the 6 months period following the date of employment termination. I understand in accepting this continuous support from MLI, I am committing to service in an MLA School. I understand these funds are applicable only to courses taken and completed at Jackson State University. I understand this reimbursement is subject to the approval of my MLA principal and employer.